FCEMS Volunteer Application Form

FCEMS Volunteer Application Form
Personal Information
Name*

First NameLast Name
Phone Number*
Email*
example@example.com
Residence Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Only select one of the following membership types.
Type of Membership*

EMS MemberAssociate MemberAuxiliary Member
Basic Requirements

EMS Membership
Are you 18 years of age or older?
Do you possess a valid Virginia Driver’s License and a good driving record?
Do you understand that applicants will be required to provide Criminal Background check sanctioned by the Virginia Office of EMS?
Do you understand that you must maintain minimum certifications of Virginia EMT, EVOC and AHA CPR to remain on the EMS Membership roster?
Additional Comments
Basic Requirements

Associate Membership
Are you 18 years of age or older?
Do you understand that applicants will be required to provide Criminal Background check sanctioned by the Virginia Office of EMS?
Do you have plans to obtain a Virginia EMT certification?
Additional Comments
Basic Requirements

Axillary Membership
Are you 18 years of age or older?
Do you possess a valid Virginia Driver’s License and a good driving record?
Do you understand that applicants will be required to provide Criminal Background check sanctioned by the Virginia Office of EMS?
Do you understand that you must maintain minimum certifications of EVOC and AHA CPR to remain on the Auxiliary Membership roster?
Additional Comments
Availability
Station Preference*

Station 1 (Town of Floyd)Station 3 (Locust Grove)Station 4 (Indian Valley)
Please select your availability for the given days and time phases*

Monday - DaysMonday - NightsTuesday - DaysTuesday - NightsWednesday - DaysWednesday - NightsThursday - DaysThursday - NightsFriday - DaysFriday - NightsSaturday - DaysSaturday - NightsSunday - DaysSunday - Nights
If accepted by FCEMS Volunteer Division, you will be required to maintain certifications applicable to the membership type offered. Can you meet this requirement? *
If accepted by FCEMS Volunteer Division, you will be required to provide service based on the Assigned Duty hours described in the membership type offered. Can you meet this requirement? *
Are you willing and able to wear an emergency pager or radio and respond to emergencies? *
Are you willing and able to participate in mandated skills assessment and training programs?*
Skills and Experience
Please indicate if you have any of the following certifications or training*

CPR - Cardiopulmonary resuscitationVirginia EMTVirginia ParamedicEmergency Vehicle Operation (EVOC)Rescue procedures- extrication, rope rescue, etc.Various Fire certificationsOther
Previous EMS Experience - Explain:
Previous Volunteer Experience - Explain:
References
Please provide atleast 1 character treference and atleast 1 professional reference.
Terms and Conditions
Please verify that you are human*
Date*

MonthDayYear
Date
Signature*
Should be Empty:

FCEMS Volunteer Application Form

Personal Information

Basic Requirements

Basic Requirements

Basic Requirements

Availability

Skills and Experience

References

Terms and Conditions